Basic Information
| Provider Information | |||||||||
| NPI: | 1518325638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HATRICK | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | CATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6620 MAIN ST | ||||||||
| Address2: | SUITE 11A.04.6 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137982400 | ||||||||
| FaxNumber: | 7137987337 | ||||||||
| Practice Location | |||||||||
| Address1: | 6620 MAIN ST | ||||||||
| Address2: | SUITE 11A.04.6 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137982400 | ||||||||
| FaxNumber: | 7137987337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2016 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP130128 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 353825804 | 05 | TX | MEDICAID |